Inspiring Medical Students to Choose Primary Care Through Lifestyle Medicine Education

Abstract

Despite a growing interest in lifestyle medicine, students at most medical schools in the United States are not receiving enough nutrition education and training in the principles of lifestyle modification to be effective at applying this knowledge to real-world clinical practice. Moreover, the rising prevalence of chronic lifestyle-related diseases and the increasing deficit of primary care providers is overwhelming the US health care system. The need for primary care physicians is being circumvented by medical students’ diminishing interest in primary care partly due to concerns about salary, prestige, and being too broad in focus. Students may also recognize that the pharmaceutically based management of chronic conditions and supplemental lifestyle recommendations are often fraught with nonadherence, resulting in the progression of disease states. However, some medical schools have incorporated the concepts and practice of lifestyle medicine into their curriculums. This integration has the potential to inspire medical students to choose a primary care specialty, because students become more adept at addressing and treating the root causes of chronic disease. Lifestyle medicine education can empower students interested in primary care to fulfill their initial desires to treat and heal that may have inspired them to want to become doctors in the first place.

The concepts, research, and practice of lifestyle medicine are starting to be integrated into medical education from preclinical years into residency.

Interest in the practice of lifestyle medicine has experienced rapid growth in recent years. ¹ The tenets of lifestyle medicine focus on educating patients about the benefits of a whole-food, plant-predominant dietary lifestyle, regular physical activity, healthy sleep habits, strategies for stress management, avoidance of risky substances, and positive social connection as primary therapeutic modalities for the treatment and reversal of chronic disease. ² Traditionally, medical students have been taught these principles under the guise of biochemistry-centric nutrition lectures, recommended guidelines for physical activity, and selected topics in preventive medicine during their preclinical years. According to a recent Association of American Medical Colleges (AAMC)-sponsored commentary on the progress of lifestyle medicine education, 90% of medical schools participating in a survey reported teaching lifestyle medicine in various forms throughout their curriculums. ³ Another recent 2017-2018 survey of curriculum topics by the American Association of Colleges of Osteopathic Medicine (AACOM) showed that 95% of the 38 schools had provided education related to lifestyle medicine topics.^4,5 Despite these AAMC and AACOM surveys that suggest lifestyle medicine education is pervasive throughout undergraduate medical education, most medical schools in the United States do not provide the minimum of 25 hours of nutrition education. ⁶ Moreover, the manner in which this content is delivered may leave students feeling underprepared to provide adequate nutrition counseling ⁷ and may not translate into practical use in a real-world clinical setting. ⁸ Two examples of medical schools that have taken a more pragmatic approach to this issue include Tulane University School of Medicine and Loma Linda University School of Medicine, both of which have integrated nutrition, exercise, and behavior change education into their curriculums. These institutions include hands-on culinary medicine experiences and incorporate a more comprehensive series of nutrition lectures with the intent of underscoring the importance and inherent value of utilizing food as medicine. ⁹ More specifically, the concepts, research, and practice of lifestyle medicine are starting to be integrated into medical education from preclinical years into residency. The University of South Carolina School of Medicine Greenville is a pace-setting institution that has integrated approximately 86 hours of nutrition, exercise, sleep, and behavior change education through a formalized lifestyle medicine curriculum incorporated throughout all 4 years of undergraduate medical education. ¹⁰ Other examples include the Western University of Health Sciences College of Osteopathic Medicine of the Pacific and the Loma Linda University Health Preventive Medicine and Family Medicine residency programs, which offer lifestyle medicine tracks and concentrations. ⁹ Progressive institutions like these are helping students and residents comprehend, at an earlier time in their careers, the value of why diet and lifestyle are among the first-line therapies for the prevention and treatment of lifestyle-related chronic diseases, many of which are the leading causes of death in the United States.

The striking prevalence of chronic degenerative disease is unquestionable as 6 in 10 adults in the United States have at least one chronic disease and 4 in 10 have 2 or more chronic diseases. ¹¹ This is leading to an increased number of patients who require long-term disease management and who also may concomitantly experience a reduced quality of life. This overburden, along with the already increasing deficit of primary care providers, is overwhelming the US health care system. ¹² Although the official mission and curricula of some medical schools may encourage producing more primary care physicians, the altruistic motivation engendered in students to enter primary care tends to devolve throughout their undergraduate medical education experience. At the start of medical school, students are inspired and idealistically dream of the kind of physician they want to become, but the long hours and demanding learning efforts swiftly take center stage. Somewhere along the journey through classes and clerkships, the realities of medicine and the current medical atmosphere may cause students to second-guess their original intentions and reconsider their initial choice of medical specialty, especially primary care. In 2008, a study of medical students in the United States found that of those individuals who were initially interested in primary care, only 30% remained so by their senior year. ¹³ This substantial shift in interest could potentially be explained by a 2016 study that surveyed medical students in the United States citing reasons for not pursuing a primary care specialty to include being too broad in focus, having a lack of prestige, and the stereotype of being less academic than other medical specialities. ¹⁴

The reality of treating chronic disease in a primary care setting may not appeal to the idea of being able to achieve tangible and timely results, as is more frequently appreciated in procedural-based specialties. A swift resolution of the disease state is not generally attributable to the treatment or management of chronic conditions in the primary care setting. The perception of nonresolution and the inevitable progression of many of these commonly encountered chronic diseases may cause medical students hesitancy or resistance when considering a career in primary care. This may be due to concerns of the specialty being mundane, repetitive, and having poor compensation for their efforts, among other factors. ¹⁵ Conventional educational models within undergraduate medical education are largely focused on the use of pharmaceutical interventions despite a nearly 50% patient nonadherence rate to medication and no clear solution for improving adherence. ¹⁶ Not surprisingly, nonadherence rates to lifestyle modification can be as high as 70%, especially when long-term maintenance of healthy habits is required.^17,18 Therefore, it is of great importance that more effort is allocated toward educating students about how to help patients sustain healthy behavior change and solidify patient understanding that plant-based eating, exercise prescriptions, and other lifestyle modifications can reduce, arrest, and potentially reverse chronic disease.

Therein lies a new opportunity to address the physician shortage, the diminishing interest in primary care, and the chronic disease epidemic in a manner that can be transformative for patients and deeply fulfilling for physicians. Lifestyle medicine empowers providers with the skills and knowledge to successfully guide patients on a path to a decreased disease burden, increased health, and an increased quality of life. The concept and practice of lifestyle medicine have the potential to reignite a passion for providing primary care in the United States. Lifestyle medicine can infuse medical students with a renewed interest in the treatment and prevention of lifestyle-related diseases. It can also empower students to educate their patients about implementing simple, yet highly impactful interventions to help halt and reverse chronic disease. At last, physicians can be eager to prescribe lifestyle recommendations, such as exercise prescriptions, dietary plans, and approaches to stress reduction with knowledge, confidence, and assurance.

In medical school, students can be taught motivational interviewing skills adapted to address unhealthy diets, physical inactivity, and poor sleep in addition to risky substance use. Faculty members who are knowledgeable and passionate about the health effects of lifestyle modification can become role models and champions for lifestyle medicine at their respective institutions. ¹⁹ Students can utilize the resources provided by the American College of Lifestyle Medicine Trainees executive board ²⁰ to increase awareness of lifestyle medicine and to establish Lifestyle Medicine Interest Groups (LMIGs). Currently, there are 28 student-led LMIGs across a variety of allied health professional institutions in the United States. ²¹ Furthermore, students and medical schools can engage with the Lifestyle Medicine Education Collaborative (LMEd) for resources and mentorship in the implementation of lifestyle medicine curricula. To date, 122 medical schools in the United States have engaged with LMEd for this support. ²²

It is also important to find providers in the community and across all health care settings who can demonstrate to students that halting and reversing chronic disease is possible and can be achieved through the application of lifestyle prescriptions or modifications. One example is the US Air Force’s Lifestyle and Performance Medicine clinic at the US Air Force Academy. Over 5000 military members have received Lifestyle and Performance Medicine consultations and the clinic provides rotation opportunities for students at all levels of medical training. The clinic has been successful in capturing metrics related to the sustained reversal of disease states such as prediabetes, type 2 diabetes, dyslipidemia, hypertension, overweight, obesity, and chronic pain. This has resulted in the improvement of military readiness and deployability of service members. Also, it has garnered interest from leadership to expand these efforts to other clinics within the Air Force (Lt Col A. Denton, Nutrition Consultant for the Air Force Materiel Command, oral communication, February 2020).

Integrating the evidence-based application of lifestyle medicine into undergraduate medical education may help increase the number of students who ultimately choose primary care. According to the American Board of Lifestyle Medicine (ABLM), since administering its first exam in 2017, a total of 1057 individuals including physicians, doctors of philosophy, masters, and bachelor level health professionals have become certified in lifestyle medicine. Of note, 761 of these professionals are physicians whose medical specialties are predominantly family medicine and internal medicine (S. Herzog, ABLM Executive Director, written communication, November 2019). This demonstrates that there is an interest in the practice of lifestyle medicine well beyond undergraduate medical education. These data support the idea that students may become interested in practicing or incorporating lifestyle medicine within a primary care setting. Future studies should examine if there is an increase in the number of medical students choosing primary care pathways by means of an early introduction to lifestyle medicine in schools where lifestyle medicine education is formally provided.

Strengthening the educational foundation of medical students with lifestyle medicine education may create an opportunity to reduce the prevalence of chronic degenerative disease throughout the nation. The demand for health care providers to educate patients about the benefits of lifestyle modification is now overwhelming.^23-25 Physicians and student doctors should attempt to adhere to the ideals inculcated within the Hippocratic and Osteopathic oaths: to prevent disease whenever possible and to preserve the health and life of patients. With the side effect profile of many pharmaceuticals and the negative consequences that health care professionals witness all too frequently from polypharmacy, it is of benefit to teach patients and future physicians an evidence-based approach to true health promotion, not just disease management.

Medical students should be informed and encouraged to practice the type of medicine they may have envisioned in their personal statements when first applying for medical school. Students need to be empowered to address the root cause of illness, guide patients back to a state of health, and teach patients about how to prevent the onset of chronic disease. By providing the educational foundation for the tenets of lifestyle medicine as well as clinical opportunities to implement these principles, future physicians can find inspiration in choosing primary care pathways. The application of lifestyle medicine can enable the next generation of medical providers to more effectively address chronic disease in the health care setting where it is most commonly treated: primary care. Students can derive satisfaction in knowing that they are not just making a difference, but that they are having a life-long positive impact for the rest of their patients’ lives. Medical students should be taught that halting, reversing, and preventing heart disease, diabetes, obesity, cancer, strokes, and lifestyle-related chronic diseases can be achieved. The practice of lifestyle medicine is not only effective and feasible but can also satisfy and fulfill those initial desires that may have inspired students interested in primary care to want to become doctors in the first place.